Claim, Authorization and Invoice for Beneficiary Travel and other Miscellaneous Medical Services

Forms and Documents

Document Name	Status
Form 10-583 Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice... Form	Modified
2900-0080 justitication.docx Supporting Statement A	2011-02-08

IC Document Collections

IC ID	Document Title	Status
28232	Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice... Form	Modified

ICR Details

OMB Control No: 2900-0080	ICR Reference No: 201009-2900-007
Status: Historical Active	Previous ICR Reference No: 200706-2900-020
Agency/Subagency: VA	Agency Tracking No: 2900-0080
Title: Claim, Authorization and Invoice for Beneficiary Travel and other Miscellaneous Medical Services
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/20/2011
	Date Received in OIRA: 02/08/2011
Terms of Clearance: Approved consistent with the following terms of clearance: OMB encourages VA to continue Departmental efforts aimed at providing respondents with a fully electronic version of associated forms that may be completed and submitted electronically and that include the recognition of electronic signatures.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2014	36 Months From Approved	05/31/2011
Responses	464,155	0	440,380
Time Burden (Hours)	33,079	0	30,391
Cost Burden (Dollars)	0	0	0

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Abstract: These forms are used to initiate and document expenditures, to claim reimbursement as well as make funeral arrangements, authorize burial benefits and other miscellaneous medical services.

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Authorizing Statute(s): US Code: 38 USC 1725 Name of Law: Reimbursement for emergency treatment
   US Code: 38 USC 1728 Name of Law: Reimbursement of certain medical expenses
   US Code: 38 USC 111 Name of Law: Payments or allowances for beneficiary travel
   US Code: 38 USC 1703 Name of Law: Contracts for hospital care and medical services in non-Department facilities
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 188	09/29/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 234	12/07/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice...	10-583, 10-7078, 10-2065, 10-2511	CLAIM FOR PAYMENT OF COST OF UNAUTHORIZED MEDICAL SERVICES ,   AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES ,   FUNERAL ARRANGEMENTS ,   AUTHORITY AND INVOICE FOR TRAVEL BY AMBULANCE OR OTHER HIRED VEHICLE

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	464,155	440,380	0	0	23,775	0
Annual Time Burden (Hours)	33,079	30,391	0	0	2,688	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden increase is due to an increase in the estimated number of respondents.

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Annual Cost to Federal Government: $1,808,547

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/08/2011

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